HMO In-Patient Specialist
Inlife Health Care Makati Full-time
JOB DESCRIPTION
- Ensure the proper monitoring of confinements of iCare members in accredited medical facilities.
- Ensure that members’ queries, concerns and/or complaints are attended to in a timely and appropriate manner prior to elevating this to the HLO Head.
- Keep abreast with current regulations and policies affecting medical services and implementation and provide proper guidance to all concerned.
- Be up to date on medical updates, utilization management, newly onboarded and renewed account benefits.
- Maintain company spiels and lines that will entice members to approach him/her regarding their benefit including medical network inquiries, concerns and LOA issuances
- Visit admitted members ensuring to discuss the member’s coverage and benefits and issue the letter of authorization (LOA).
- Monitor daily the member’s progress chart to know member’s needs and current medical condition.
- Assist the member during discharge by checking hospital charges and professional fees to maximize member’s benefits and to prevent incurrence of excess charges beyond the benefit coverage and advise member on non-covered charges.
- Build and maintain good rapport with iCare’s designated Hospital Care Director (HCD) in the hospital, iCare’s roster of accredited physicians and provider personnel.
- Visit hospital administrators, HCDs and iCare- accredited doctors to act promptly on their concerns (i.e., unpaid claims, distribution of checks, implementation of new hospital policies, etc.).
- Assist in creating and organizing processes, information acquisition and appropriate agreements to ensure alignment with the company's policies on Health & Safety, Quality Assurance, Marketing & Brand Management, and Risk & Integrity Management.
- Ensure proper gatekeeping and utilization management through:
- Determination of validity of the member status, benefit coverage and maximum available limit prior issuance of LOAs through information garnered from the Medical Account System (MAS).
- Review of cases and checking necessity for confinement and need for medical procedure.
- Coordination of catastrophic cases to superior for case management.
- Distribute service evaluation survey forms and ensure that the targeted confidence level and margin of error is met on a monthly basis.
- Receive comments, suggestions and feedback and collates survey results.
- Assist the Provider Management Division by:
- Increasing the roster of accredited medical facilities especially physicians.
- Do on the spot or provisional accreditation of member accessed/requested physicians and/or medical facilities.
- Updating the records of physicians as the need arises.
- Collecting and/or releasing documents to and from accredited medical facilities.
- Coordinating with accredited medical facilities for payment, OR follow-ups or lifting of suspensions.
- Work with internal and external leaders in areas affecting department operations.
- Contribute to create processes for Medical Audit and ensure proper application through an established and agreed medical audit exercise.
- Participate in current process review and development of new and / or revised work processes, policies and procedures relating to Utilization Management responsibilities.
- Submit reports relative to duties and responsibilities.
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